Psychiatric
Deviance: Diagnostic Labeling

Part 1. "On Being Sane in Insane Places"

Introduction to
Rosenhan's Study of Psychiatric Labeling

In his book Outsiders
(1963), Howard Becker presented a hypothetical example of a law-abiding
boy who was falsely accused and arrested as a delinquent to illustrate
a central conceptual principle of labeling theory: it's not what you do,
but how others define you that makes you socially deviant. Becker speculated
that if such "bum raps" can occur in the legal system where
rules of evidence and due process protect the accused, then cases of false
accusation "probably occur much more frequently in nonlegal settings
where procedural safeguards are not available" (1963: 20). A fascinating
study by David L. Rosenhan assigned for this unit, "On Being Sane
in Insane Places" (1973), offers some compelling empirical support
for Becker's speculation. Among other things, this observational study
demonstrates that false accusations of deviance-or, rather, false diagnoses-are,
indeed, a very real possibility in psychiatric settings.

This and other discoveries
came about through the novel but effective strategy Rosenhan's participant
observers used to gain new insights into psychiatric social control: they
put themselves on the receiving end of it. Rosenhan, a psychologist, and
eight other normal people (including three psychologists, a pediatrician,
a psychiatrist, a painter, a housewife, and a graduate student) individually
went to the admissions offices of 12 different psychiatric hospitals and
complained of hearing voices that said "empty," "hollow,"
and "thud." It is important to note that this particular set
of "symptoms" was completely contrived and had never been
reported in the psychiatric literature. Nonetheless, in every case
these "pseudopatients" were falsely diagnosed as having a severe
mental disorder and were admitted to the hospitals on a voluntary basis.
Once the pseudopatients were taken to a psychiatric ward, they ceased
reporting any symptoms and behaved just as they normally would. To be
discharged from the hospital, each pseudopatient had to convince the staff
that he or she was really sane.

Some of the results of this
study might strike you as startling, even nightmarish. Despite their apparently
normal behavior following admission as voluntary patients, Rosenhan and
his collaborators were held in these institutions for an average of 19
days. In one case, a pseudopatient was hospitalized for nearly two months!
Even though they eventually succeeded in gaining discharges, none of the
pseudopatients was certified to be truly normal or sane upon release.
In all 12 instances, the observers left the institutions with the psychiatric
label "schizophrenia in remission" entered into their permanent
records.

Rosenhan's dramatic findings
on the ease of admission and the difficulty of discharge in psychiatric
institutions became the subject of considerable controversy, as we shall
see later. However, observational data gathered by the researchers during
the course of their hospitalization are of even greater significance for
a sociological understanding of psychiatric treatment as a process of
social control. The pseudopatients took detailed field notes on routine
patterns of activity as well as unusual incidents they observed on the
psychiatric wards. Most of Rosenhan's descriptive analysis of the experience
of psychiatric hospitalization is based on qualitative data taken
from these notes. Throughout his article, Rosenhan uses specific anecdotes
from field notes to typify or illustrate general observations and common
impressions reported by the pseudopatients. For instance, consider the
following "conversation" between a pseudopatient and a psychiatrist:

Pseudopatient: Pardon
me. Dr. X. Could you tell me when I am eligible for grounds privileges?

Physician: Good morning,
Dave. How are you today? [Moves off without waiting for a response.]

If, as Rosenhan indicates,
this type of encounter were observed frequently on the hospital wards,
what would you conclude about the nature or quality of social interaction
between patients and staff? Rosenhan's conclusion, which he attempts to
document with this and other anecdotal evidence, is that hospital staff
members tend to "depersonalize" patients and avoid meaningful
social contacts with them. Rosenhan s skillful presentation of these qualitative
data not only provides a rich description of the peculiar features of
the process of interpersonal avoidance but also conveys to the reader
a subjective sense or feel for its dehumanizing impact on patients. By
encouraging an understanding of social control from the underdog's point
of view, Rosenhan s qualitative analyses serve as an excellent example
of the humanistic approach to deviance research advocated by Becker and
many other sociologists within the labeling tradition.

Despite the intuitive appeal
of qualitative insights from participant observation studies, hard-nosed
researchers often object that impressionistic or "soft" data
can all too readily be slanted or selected to fit the preconceived biases
of the investigator. Specifically, isn't it possible that Rosenhan chose
to emphasize a relatively few, shocking incidents of depersonalization
and that he could just as easily have cited numerous anecdotes portraying
warm and therapeutic relationships between staff and patients? Or, when
vague and implicitly statistical terms like frequently or rarely
are used to describe certain activities, isn't it reasonable to ask exactly
how frequently or how rarely these actions were observed
to occur? Apparently anticipating such objections, Rosenhan instructed
his observers to gather quantitative data on a variety of routine
behaviors and events that occurred during their hospitalization. Thus,
Rosenhan was able to buttress many of his generalizations about interpersonal
reactions to patients with quantitative evidence. For example, his article
includes a table showing data from four hospitals where pseudopatients
kept a count of the responses they received after approaching members
of the staff with simple requests for information. When you read the article,
look at the percentages of encounters in Table 1 in which staff did not
even stop to make eye contact with pseudopatients, and judge for yourself
whether Rosenhan is justified in characterizing staff-patient relationships
as "depersonalized."

At this point, however, it
will probably come as no surprise to you that many psychiatrists do not
believe that Rosenhan s conclusions are justified by his evidence. His
article became the subject of almost unprecedented controversy following
its publication in the prestigious journal Science. In no fewer
than 15 letters to the editor of Science (Fleischman et al., 1973)
and seven critical essays prepared for the Bulletin of the Menninger
Clinic (Wiedeman et al., 1973; Hoizman et al., 1973), psychiatrists
voiced their particular concern with Rosenhan's conclusion that "we
cannot distinguish the sane from the insane in psychiatric hospitals"
(1973: 257). Rosenhan's critics attacked his findings on the false diagnoses
of 12 pseudopatients and defended the ability of the psychiatric profession
to distinguish various forms of psychoses from "nonpsychotic"
(normal?) behavior. At least one critic implied that the pseudopatients
may not, in fact, have acted nor been as normal as Rosenhan indicated
in his article! At the other extreme, several psychiatrists attempted
to account for his findings on admissions and discharges by arguing that
the pseudopatients had by chance encountered 12 hospitals with unusually
incompetent diagnostic procedures.

Whatever the scientific merits
of Rosenhan's observational research, the intense critical reaction to
the issues he raised about the validity and reliability of psychiatric
diagnoses highlights a crucial ideological implication of his work. By
questioning the credibility of diagnostic labels, Rosenhan, in effect,
challenges the legitimacy of the medical model of deviance upon which
psychiatric social control is based. Indeed, the goal of Rosenhan's
analysis is not only to describe the uses of social control in psychiatric
settings but also to raise the more troublesome issue of whether individuals
should be subject to the potential abuses of being labeled as mentally
ill. In this respect as well as in many others, Rosenhan's study falls
squarely in the humanistic, value-engaged tradition of Becker and other
labeling theorists.